Tuesday, August 23, 2011

This is not a breastfeeding blog

I am a committed breastfeeder and my children are weaning naturally (in years, not months). It's very important to me and sometimes I write about it.

But I have no formal training and there are plenty of expert breastfeeding sites available.

There but for the grace of...

Each mother faces her own journey and obstacles. This is not about judgement.

Had my sister not stood up for my first child against the hospital staff, nobody else (including me) would have stopped his tiny body from being pumped full as he could hold with artificial milk (formula).

I could now (unnecessarily) be a bitter wannabe breastfeeder as well as a bitter wannabe homebirther.

Instead, I have a dream. It's about a different world of baby feeding.

My dream

Breastfeeding

Breastfeeding is the normal way to feed every baby...and any young child still needing extras on top of solid foods.

Mothers see breastfeeding from childhood on, within the home and out in public. So do fathers.

Before the baby's birth, mothers learn even more about breastfeeding the same way we currently learn about birth. Every mother has already joined a community breastfeeding support group (like La Leche League) before she even looks her own baby in the eye.

There are lots of trained breastfeeding experts who really know how breastfeeding works and why it sometimes doesn't work. They're available to all new mothers, especially those who are at known risk for breastfeeding problems.

Artificial milk is rarely needed. It would be available only by prescription, not in the supermarket. We know the artificial can't be as good, especially for such a complex substance as biological mammalian milk.

We don't spend money trying to improve artificial milk or show that it is really just as good - we need that money to support our wet nurses and supplies of donor breast milk.

It takes a mother...and a village

Mothering your own children, including breastfeeding and natural weaning, is as highly respected and valued an occupation as any that is commercially paid.

We accept the general benefit to all society of having young children in the consistent care of their own mothers.

There is tax relief and real social support available to encourage mothers to be the first, best, and most available childcare for the crucial first few years.

Impossible?

Very possible, with a lot of baby steps.

Milk banks - already increasing again worldwide, now that safe testing is available. Please support the New Zealand Maternity Manifesto, which asks our politicians to support milk banks among other positive initiatives.

The money - already in circulation, spent on artificial milk. Now we just need to get real.

The attitude? That's up to you and me, baby.

Feeding in Nature

A tigress has just birthed cubs in an animal reserve. Would her carers decide, "This tiger has a more important job to do as an exhibit in our reserve. We will take her cubs and feed them artificial milk so she can return to her normal life as soon as possible. Nobody has proved that it isn't just as good."

If they did, imagine the reaction of the tigress.

Artificial milk for human babies is largely created from milk stolen from a mother cow or goat and her baby. These placid animals have no choice when their milk, their babies, and their mothering role are taken from them.

22 comments:

Is there any evidence that milk from donor banks has advantages over formula for healthy, term babies? As far as I'm aware, the only available research has been done in premature babies, and it's not necessarily possible to extrapolate.

We're so used to hearing about breastmilk as the better option in all situations, it's easy to forget that frozen, thawed, heat-treated, stored breastmilk from a bottle is different in many ways from fresh breastmilk directly from the breast. For example, some of the benefits (dental benefits and at least some, possibly all, of the protection against ear infections) seem to be due to the different sucking action required to drink from a breast rather than a bottle. So donor milk from a bottle wouldn't give those benefits. We don't know how much of the protection against GI infections is due to innate properties of breastmilk, and how much is due simply to the fact that it doesn't sit around with bacteria multiplying within it. It's also plausible that freezing, storing, and heat treating it could destroy some of the immune factors and cells within it. So I'm really interested to know what research has been done on properties of stored pasteurised breastmilk, and on its use outside the NICU setting. It does seem likely to me that there's room for quite a lot more research here before setting these banks up as a widespread thing.

Frozen breastmilk is not the same as fresh breastmilk. Even breastmilk stored for a day and fed via bottle is not the same. Some components will be lost.

(Of course, millions of people worldwide drink cow's milk given such processing in the belief that it's healthy - you may not be one of them.)

I would agree that employing wet nurses is the superior option to milk banks, when possible. And with a culture shift, there's no reason it couldn't be.

By the same logical process, formula made from cow milk (or other) proteins is absolutely not the same as any sort of human breastmilk. Most components will never have been there in the first place.

It might be worthwhile researching processed breastmilk as a spur to promote wet nursing. But not as to find evidence for an absurdity like "maybe we can prove formula is actually just as good" when human breastmilk could be made available.

OK, that seemed fine - must have just been too long a comment. I'll try posting just the first part of it.

Good-quality science doesn't start out either by saying 'How can we prove that X is the case?' or by saying 'No, X couldn't possibly be the case, that's too much of an absurdity to bother looking into'. It starts out with the attitude 'If we're honest, we don't actually know whether X is the case or not. Sure, we have our beliefs and our assumptions and our preconceptions on the matter – but those aren't the same as knowing. So let's design as unbiased a research study as we can manage in order to look at the question of whether X is the case or not.'

The reason I'm wondering about this is because of the practical difficulties and expense that would be involved in making breastmilk as available to every baby unable to breastfeed as formula currently is. I was just reading a section on breast milk banking in ' Reclaiming Breastfeeding for the United States: Protection, Promotion and Support' by Karin Cadwell & Cindy Turner-Maffei (I found this at books.google.com – most of the chapter on breastmilk banking is available online). One of the things it said was that, in 2001, banked breastmilk cost $2.75 an ounce plus shipping costs, and that this fee didn't begin to meet the costs of processing and testing – milk banks break even at best, and often run at a loss. So, out of curiosity, I looked up the cost of a common brand of powdered formula and worked out how much that cost per ounce. In US currency, it worked out at just over *six cents*. And that would include most of the shipping costs (as it would include the cost of getting it to outlets that are easily accessible to families).

With those kind of cost differences, I just don't see how human milk could be provided as a universal replacement to human formula without either massive unregulated donation (riskier than I'd want), or massive government subsidy. If it's the latter -well, I'm sure the money could be made available, but where would it be taken from? No matter how much government inefficiency you do away with (and I'm sure there's plenty), or how much taxes get increased, you're still only going to end up with a finite amount of money to spend on increasing health and social welfare in the country. Given how many competing claims there are for that money, I think somebody certainly *should* be looking at the benefits of rolling out a scheme like this for every baby in the country, to decide whether that really is the most good that that money could do.

Good-quality science doesn't start out either by saying 'How can we prove that X is the case?' or by saying 'No, X couldn't possibly be the case, that's too much of an absurdity to bother looking into'. It starts out with the attitude 'If we're honest, we don't actually know whether X is the case or not. Sure, we have our beliefs and our assumptions and our preconceptions on the matter – but those aren't the same as knowing. So let's design as unbiased a research study as we can manage in order to look at the question of whether X is the case or not.'

The reason I'm wondering about this is because of the practical difficulties and expense that would be involved in making breastmilk as available to every baby unable to breastfeed as formula currently is. I was just reading a section on breast milk banking in ' Reclaiming Breastfeeding for the United States: Protection, Promotion and Support' by Karin Cadwell & Cindy Turner-Maffei (I found this at books.google.com – most of the chapter on breastmilk banking is available online). One of the things it said was that, in 2001, banked breastmilk cost $2.75 an ounce plus shipping costs, and that this fee didn't begin to meet the costs of processing and testing – milk banks break even at best, and often run at a loss. So, out of curiosity, I looked up the cost of a common brand of powdered formula and worked out how much that cost per ounce. In US currency, it worked out at just over *six cents*. And that would include most of the shipping costs (as it would include the cost of getting it to outlets that are easily accessible to families).

With those kind of cost differences, I just don't see how human milk could be provided as a universal replacement to human formula without either massive unregulated donation (riskier than I'd want), or massive government subsidy. If it's the latter -well, I'm sure the money could be made available, but where would it be taken from? No matter how much government inefficiency you do away with (and I'm sure there's plenty), or how much taxes get increased, you're still only going to end up with a finite amount of money to spend on increasing health and social welfare in the country. Given how many competing claims there are for that money, I think somebody certainly *should* be looking at the benefits of rolling out a scheme like this for every baby in the country, to decide whether that really is the most good that that money could do.

For point 1, I'd like to point out that nobody is going to seriously investigate whether artificial limbs are as good or better than real limbs. Whether artificial teeth are as good or better than real teeth.

I believe there IS a genuine point of absurdity, even for "objective" science. We have simply (due to a lot of political and commercial pressure) decided en masse NOT to apply this to artificial milk.

For points 2 and 3, if you read my vision, society must support women breastfeeding their own children - as if we really believed it was natural and desirable and important that they do it, not like now.

The issue of human milk being as available as formula is not relevant. While replacement milk is so heavily used by mothers, we are already failing.

The rich in most developed countries have more money than they could spend in multiple lifetimes.

A heartbreaking proportion of actual tax take is spent on killing people in other countries to protect the current world order and continue the dominance of fossil fuels in our economy.

Where is the money going to come from? Don't be fooled into throwing up your hands. There's always money for what your society considers important. At the moment, our society prefers inequality and death.

I note again that you are only discussing the Milk Bank portion of my vision and not mentioning the Wet Nurse employment possibilities.

Sorry - because I only posted the first half of my original comment (yes, believe it or not, the original was so long that that was just the first half!) some of my points got missed off the end. I meant to come back and post the next bit, but was in a bit of a rush and didn't have time.

First off, I think the question is not just 'Is donated milk better than formula?' The question is 'How much better?' You're talking about massive societal spending, not to mention massive inconvenience for parents who don't have enough freezer space to store the frozen milk (which, unless furthe research leads to current guidelines on the storage of thawed milk being relaxed, would mean having to get to the milk bank every single day for their baby's entire first year). Before committing to that, yes, I do think it completely appropriate to take a good look at whether the benefits we get in return are large enough to be worth it. Yes, society will make enough money for what we consider to be important - I think it's a good idea for us to look first at how important it is.

What I'd like to see, first and foremost, is the current milk bank programme rolled out to the point where every baby in special care units (barring rare metabolic conditions that preclude taking normal breastmilk) would be given human milk rather than formula as standard. That would be far more feasible, and, from what I understand, there *is* good evidence for using human milk in this setting. Then, when this was achieved, we could look at getting enough extra to do some pilot studies comparing banked milk with formula in various situations - in babies or children who had particular health conditions, in babies at increased genetic risk of particular health problems, and in groups of normal healthy babies chosen at random. This would give us an approximate idea of the size of the benefits in various groups (although it would be simply impossible, as far as I can see, to look at some rare conditions like SIDS in that way).

I'm all in favour of massively increasing the support given to breastfeeding women. However, you're advocating a society in which formula is only available in rare occasions on prescription. That would mean making it possible for EVERY woman who couldn't produce enough milk to breastfeed fully (and current best estimates, according to the WHO, suggest that this might be anything between 1 and 5% in the Western world), or who had HIV, or who needed medication that was incompatible with breastfeeding, or was so deeply distressed after sexual abuse that she was unable to face breastfeeding, or who had adopted a baby and couldn't manage to produce sufficient milk through adoptive nursing, to be able to get hold of sufficient screened human milk to provide for their babies.

As far as the wet nurse idea goes, how were you seeing that as working? Do you mean the wet nurse would pump the milk to donate, or that she would literally move into the family's house and be available to feed the baby day and night, or what?

Your perspective poses problems with using donated milk as being practically insurmountable. I disagree. Your extreme of "parents with not enough freezer space" is just that - an extreme.

Your shock that 1% to 5% of women who don't produce enough milk plus the other extreme circumstances might somehow be provided with real human milk is confusing. Precisely what do you think happened before formula was invented?

Ideally, the baby is breastfed, so ideally, a wet nurse is a live in position, just like many other child carers currently are. There are many other flexible choices if you use your own imagination instead of simply your sceptism.

Jess, what happened before formula was invented was that a lot of babies died. A lot of others survived but went hungry for much of their infancy. Also, it was considered normal in the richer parts of society for a mother not to raise her own children – many would actually be sent to stay with the wet nurse for the first couple of years of their lives before coming home, while in other situations the babies would be raised in the nursery by the nanny while the mother saw them briefly once a day. If those sorts of situations are considered acceptable, then, yes, wet-nursing as a replacement for formula can work. I think we can both agree that they aren't.

Families that have live-in childcare are usually families in which both parents are working and thus earning. In families with only one wage earner, there isn't usually the spare money to pay someone else to be available 24/7. So wet nursing would only really be available to the very well-off. Also, live-in nannies normally get most evenings/nights/weekends off and a certain amount of paid leave per year, all of which would be hugely more difficult to arrange in a wet nursing situation. I'm also wondering how they would manage nights – would the baby have to sleep in the wet nurse's room, would the wet nurse have to sleep in the parents' room, or would the parents have to come and bang on the wet nurse's door every time the baby woke up?

Jess, these problems do exist – I'm not making them up. Yes, some families do not own freezers. Yes, wet nursing does have a lot of logistical problems over and above other forms of childcare. Yes, breastmilk screening is much more expensive than manufacturing formula. Yes, breastmilk storage poses problems that powdered formula storage does not. Yes, these problems would cause difficulties for significant numbers of families in the kind of society you're proposing. If you can see easy solutions to these problems, then that's wonderful – I'm happy for you to post them. I'm asking because I can't see easy solutions and because these problems won't just magically disappear if we ignore them.

I'm not sure how to explain this better to you. This is a vision that not only includes milk banks and wet nurses but also an economic value on motherhood and breastfeeding.

You keep asking "how in THIS society could my vision exist because of all of these problems in THIS society?" It doesn't and it can't, because we don't value motherhood as much as we do war and supporting massive inequality. We plunder huge resources for anti-community behaviour.

If you expect me to solve those problems easily by myself, I wonder why, instead of recognising that these problems exist and are directly to blame for our horrendous underresourcing of a healthy society that supports natural relationships.

We could EASILY pay for a small freezer for those mothers who are unfortunate enough both not to produce milk and not to afford a freezer...in a society that values breast milk as necessary to health.

I know you want scientific proof before you want to act. That's your prerogative. You might want to consider how many decades cigarettes were sold before anything like scientific proof was allowed to come to public attention - for much the same reasons.

Even in our society as it is, I do not see the barriers to wet-nursing as impossible as you. Again, it used to happen. Many jobs already require flexible working hours, and some are very inconvenient. And our society is chronically underemployed.

Did you not respond to your baby at night? Why do you consider it impossible that someone might agree to do that for compensation? Night nurses do, (and again I can only assume that for the sake of arguing you are intentionally ignoring tools such as baby monitors that carers use to handle nights, if not cosleeping). Those that won't might indeed pump for the night hours. Yes, those compromises I see as worthwhile to avoid feeding artificial milk.

It's clear you don't agree, but I'm not certain what you are trying to accomplish...you don't have to support my vision but you're not going to convince me it's impossible or even impractical, given an reallocation of priorities and funds that could only be considered admirable.

To clarify a couple of points: my concerns over how a family in a wet-nurse situation would handle night-time aren't related to whether anyone out there would agree to being paid to get up at night to care for somebody else's baby, but to how a mother would feel about having her baby sleep in somebody else's room. Sure, some mothers currently do this in the short term to give themselves a break, but I think expecting mothers to make it a regular thing throughout the baby's infancy would be a different kettle of fish. I'm also wondering what it would do to the mother-child relationship to have the baby always fed by someone else *and* sleeping in the same room as someone else – seems to me there'd be a real risk that the baby's primary attachment would be to the wet nurse (who is then going to move onto another family in a few years' time) rather than to the mother or father.

Flexible working hours are one thing - *never* getting time off without enormous practical difficulties (both finding another way to feed the baby and pumping several times a day to maintain milk supply) are another. Yes, it worked once upon a time – in a society where few other jobs were available to women, where there was no expectation of having a certain number of days off in a year or even of expecting time to travel to see family who lived somewhere else, and where people weren't too bothered if a wet-nurse's supply wasn't quite sufficient for a newborn because it was expected that babies would scream a lot during their infancy and sometimes die for no apparent reason.

My point is not that nobody would ever be able to make wet-nursing work in this day and age, but that, once you add up all the practical barriers, including the cost of a live-in 24/7 position, it's going to be a solution viable for only a tiny minority. The rest would depend on milk banks and informal milk-sharing solutions, and making those solutions easily, universally and safely available on the kind of 24/7 basis required to feed a baby would be extremely difficult.

Anyway, I am *not* expecting you to solve these problems easily. I am trying to point out to you that they are not easy to solve. They would be difficult, complicated, and extremely expensive to solve. What you're trying to present as a highly desirable and quite easily achievable way of doing things would actually have major disadvantages. And, whatever the benefit of banked milk may be, it *is* going to be less than that of breastmilk. We just don't know how much less.

So, this is why I am saying that, before doing this, we *should* be looking at whether or not it's worthwhile. Sure, there are things that this society spends our money on that are less worthwhile. If we take all that money that is currently being spent on the things you don't agree with and spend it, instead, on making sure that nobody has to go homeless or hungry or without medical care... will there still be enough left over for the provide-every-baby-with-breastmilk project? I don't think we can assume that.

To go back to your previous analogy – yes, of course a person's *own* real limbs are far better than artificial ones. However, when someone loses a limb and needs a replacement, it is *not* valid to assume that a transplanted limb from another person must be far better than an artificial limb just because it's real, and to leap from that to a belief that the way forward is to roll out a programme of limb transplantation for almost everyone missing a limb, without any attempt to examine how transplanted limbs compare to artificial limbs in practice or to look at how the benefits and drawbacks of such a programme might stack up. Transplanted limbs are, in fact, not nearly as good as the limbs a person was born with, and come with their disadvantages. Should we be looking at ways of improving limb transplantation techniques, to try to make this a better option for more people both short- and long-term? Absolutely. Should we be rushing ahead with plans to roll out a limb transplantation programme for everyone who's lost a limb, absolutely without regard to whether the benefits that transplanted limbs *currently* have over artificial limbs are great enough to justify such a programme? No. That reallocation of priorities would not be 'admirable' – there would be a significant risk that it would do more harm than good.

Jess, I agree with several of the things you're saying – that there should be far more support for breastfeeding than there is now, that banked milk should be much more widely available than it is now, that we should all be looking harder at this as an option. What I cannot support is this idea that we should plough ahead with trying to make donated milk the option for almost *anyone* who cannot breastfeed – indeed, to the point of actually preventing women from choosing formula without medical permission – without doing a lot more research into whether this would be a good idea overall or not.

We have different assumptions for the evidence for the probable harm of formula and the barriers to making breast milk an integrated part of mothering instead of formula for that minority who actually can't.

Therefore our conclusions about results in as yet hypothetical situations will continue to differ.

Hopefully someday we will be able to continue this in a more concrete way. I look forward to seeing your own vision someday.

I understand that historically, when wet nurses were used, it was often not good news for the natural child of the woman doing the wet nursing for a richer mother. I know tandem nursing is possible, but there are indications that the wet nurse doing this as a living would sometimes abandon her own child at an orphanage. I have no references. This is overheard. I just thought I would raise it.

I'm really glad you raised this point - wet nursing as it was then is not a very good model for my vision, is it?

I see wet nursing as a good solution for a medical inability to breastfeed, not simply a method for richer mothers to outsource their baby care, because I believe milk straight from the natural mother is superior whenever possible. And certainly not at the expense of the mothering of the wet nurse's child.

Those facets reflect the stark economic imbalances of the day, and arguably we are still suffering from those.

Like any job, wet nursing would be safest either within small intimate groups, or as a protected and formalised role in the larger community.